A nurse is receiving a change-of-shift report for a group of assigned clients. The nurse anticipates which of the following activities first in delivering client care using the nursing process?
Set client-centered, measurable and realistic goals.
Critically analyze client data to determine priorities.
Determine effectiveness of interventions.
Collect and organize client data.
The Correct Answer is D
A. Set client-centered, measurable and realistic goals: This occurs during the planning stage, after data collection and analysis.
B. Critically analyze client data to determine priorities: This step happens after data collection during the diagnosis phase.
C. Determine effectiveness of interventions: This is part of the evaluation stage, which comes after planning and implementation.
D. Collect and organize client data: This is the first step in the nursing process, where the nurse gathers comprehensive information about the client's physical, psychological, sociocultural, developmental, and spiritual needs.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. Inspection: Inspection is always the first step in any physical examination, including abdominal assessments. It allows the nurse to visually assess the abdomen for distension, asymmetry, discoloration, or other abnormalities.
B. Percussion: Percussion is performed after inspection and auscultation. It helps assess the density of abdominal contents but should not be the first step.
C. Palpation: Palpation is performed last in an abdominal exam to avoid altering bowel sounds and causing discomfort. It should be done after inspection, auscultation, and percussion.
D. Auscultation: Auscultation is typically the second step after inspection to listen for bowel sounds before palpation and percussion, which might alter them.
Correct Answer is C
Explanation
A. Sheepskin heel pad: A sheepskin heel pad provides cushioning to prevent pressure ulcers but does not prevent plantar flexion contractures as it does not keep the foot in a neutral position.
B. Abduction pillow: An abduction pillow is used to maintain hip abduction and alignment, typically after hip surgery. It does not address foot positioning or prevent plantar flexion.
C. Footboard: A footboard helps maintain the feet in dorsiflexion, preventing plantar flexion contractures. It keeps the feet at a 90-degree angle to the legs, which is essential for preventing contractures.
D. Trochanter roll: A trochanter roll is used to maintain the alignment of the hips and prevent external rotation of the legs. It does not prevent plantar flexion contractures.
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